Thank You for your interest in our career opportunities! Fill out the application below to get started!

Step 1 of 3

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Please Indicate purpose of application: (choose one or both):

Application Purpose * Required

At Home

Community

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any
basis including race, color, religion, sex (including pregnancy, gender identity, and sexual orientation),
national origin, age (40 or older), disability or genetic information.

Today's Date - must be mm/dd/yyyy format * Required

Date Format: MM slash DD slash YYYY

Applicant Name: * Required

FirstMiddleLast

Applicant Address * Required

Street AddressCityStateZIP Code

Phone # * Required

Cell #

Email * Required

Are you a U.S. Citizen * Required

Yes

No

Are you 18 years or older? * Required

Yes

No

Are you an alien authorized to work in the U.S.? * Required

Yes

No

Are you a veteran? * Required

Yes

No

Position applied for? * Required

How did you hear about us? * Required

Income preference: * Required

Number of hours preferred: * Required

Date available for employment: - must be mm/dd/yyyy format * Required

Date Format: MM slash DD slash YYYY

Days available to work:

Sun

M

Tu

W

Th

F

Sat

Available Hours:

Sun * Required

M * Required

Tu * Required

W * Required

Th * Required

F * Required

Sat * Required

Are you available to work nights? Choose one:

Night Availability * Required

Yes

No

Are You willing to provide Transportation:

Yes

No

*Many caregiver positions require the caregiver to transport a client

Do you have dependable transportation?

Yes

No

Make,model, and year of car

Experience

Discuss any training or experience working with the elderly: * Required

What would you like most about working with the elderly? * Required

What would you like least about working with the elderly? * Required

Skills

Companionship * Required

yes

no

Vacuuming * Required

yes

no

Laundry * Required

yes

no

Bathing/Dressing * Required

yes

no

Dusting * Required

yes

no

Grocery Shopping * Required

yes

no

Grooming * Required

yes

no

Clean Bathroom * Required

yes

no

Cooking * Required

yes

no

Incontinence * Required

yes

no

Clean Kitchen * Required

yes

no

Driving * Required

yes

no

Transfer/Assist * Required

yes

no

Bed Linen Changes * Required

yes

no

Medication Reminders * Required

yes

no

Employment History:

Begin with the most recent. Please go back at least five years and tell us about your work history. Use reverse side of sheet if additional space is required.

Upload Your Resume:

How many jobs have you had in the past 5 years?

May we contact your current employer? * Required

yes

no

Company * Required

From - must be mm/dd/yyyy format * Required

Date Format: MM slash DD slash YYYY

To - must be mm/dd/yyyy format

Date Format: MM slash DD slash YYYY

Currently Employed?

Present

Location * Required

Reason For Leaving: * Required

Job Title * Required

Duties * Required

Supervisor * Required

Pay Rate: * Required

May we contact this employer? * Required

yes

no

Company * Required

From - must be mm/dd/yyyy format * Required

Date Format: MM slash DD slash YYYY

To - must be mm/dd/yyyy format

Date Format: MM slash DD slash YYYY

Currently Employed?

Present

Location * Required

Reason For Leaving: * Required

Job Title * Required

Duties * Required

Supervisor * Required

Pay Rate: * Required

May we contact this employer? * Required

yes

no

Company * Required

From - must be mm/dd/yyyy format * Required

Date Format: MM slash DD slash YYYY

To - must be mm/dd/yyyy format

Date Format: MM slash DD slash YYYY

Currently Employed?

Present

Location * Required

Reason For Leaving: * Required

Job Title * Required

Duties * Required

Supervisor * Required

Pay Rate: * Required

SPECIAL SKILLS AND/OR TRAINING

Education Data:

High School:

Name

Degree Earned

Course of Study

College:

Name

Degree Earned

Course of Study

Other:

Name

Degree Earned

Course of Study

Have you ever convicted of a crime? * Required

yes

no

Please explain:

Business References

Name

Address

Relationship/Years

Phone

Name

Address

Relationship/Years

Phone

Name

Address

Relationship/Years

Phone

Personal References

Name

Address

Relationship/Years

Phone

Name

Address

Relationship/Years

Phone

Name

Address

Relationship/Years

Phone

Name

Address

Relationship/Years

Phone

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers
given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I
understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my
application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus,
to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools,
companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons,
schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also
understand that the use of illegal drugs is prohibited during employment. Company policy requires submitting to drug testing to detect the use
of illegal drugs prior to and during employment. I understand that I am required to abide by all rules and regulations set forth by the employer. I
also understand that if hired, I will be an at-will employee and both parties have the right to terminate employment at any time.

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